Patient Management and Clinical Recommendations During The Coronavirus (COVID-19) Pandemic

Update #4: The ASRM COVID-19 Task Force continues to support the measured resumption of care. Consistent with a long-term view of the pandemic, moving forward, the Task Force now plans to release updates to its recommendations every four weeks, unless conditions warrant greater frequency. Read the full document here

The world has been suffering a pandemic of a proportion not previously experienced in this century, with higher infectivity and mortality than previous epidemics. While acknowledging that infertility is a serious disease that requires treatment in a timely manner, in its Recommendations of March 17, 2020 and in the subsequent Updates, No. 1 and No. 2, the ASRM Coronavirus/COVID-19 Task Force (the “Task Force”) recognized the need to delay any but the most urgent of reproductive care cases. This was necessary as the extent of the COVID-19 pandemic, its viral transmission rate, its impact to reproductive well-being and in pregnancy, and the ability of health systems to cope were yet unknown, at least for the U.S.

With the passage of time, significant knowledge was gained as an increasing number of patients whose care had been delayed were in a situation that had become more urgent. Therefore, in Update No. 3 (American Society for Reproductive Medicine (ASRM) Patient Management and Clinical Recommendations during the Coronavirus (COVID-19) Pandemic - Update No. 3, April 24, 2020) the Task Force issued recommendations for gradually and judiciously resuming the delivery of reproductive care.

The Task Force continues to support the measured resumption of care. In the current update (Update No. 4), additional clarification and information is provided with regards to testing, pregnancy, and third-party reproduction, and the specifics around its recommendations for the use of Personal Protective Equipment (PPE) to mitigate risk of infection during the delivery of reproductive care.

While it is unclear how long the pandemic will last, it is highly probable that we will need to be operating in a COVID-19 environment for several months, at least until an effective and safe vaccine becomes widely available. Consistent with this long-term view, moving forward, the Task Force now plans to release updates to its recommendations every four weeks, unless conditions warrant greater frequency.

Since the last update, the Task Force has observed that:

To date, worldwide, there have been almost four million confirmed cases of COVID-19, the disease produced by the virus SARS-CoV-2, with more than 1.3 million confirmed cases and more than 79,000 deaths in the United States (U.S.) alone.

While no community is unaffected, the prevalence of the disease varies widely throughout the U.S. In some areas, mitigation strategies have led to a “flattening of the curve” or a sustained decrease, while other areas are still seeing an increase in the rate of new cases and deaths over time.

Many parts of the country are now in the process of loosening mitigation strategies. At the same time, viral testing capacity is increasing and contact tracing algorithms are being developed. The impact of these measures on COVID-19 prevalence is not yet known. While peak resource utilization resulting from COVID-19 disease has severely burdened healthcare systems in some communities, other parts of the country have not seen similar stress to their healthcare safety net. Overall, these developments suggest that most patients currently falling ill with COVID-19 will be able to access the care they need.

Over time, it has become apparent that the ebb and flow of COVID-19 is not accurately predictable despite the use of multiple models. It is not clear, for example, whether a sustained plateau might be followed by a gradual resolution or by a resurgence of new viral cases. Given this, decisions regarding patient care must remain flexible.

No vaccine yet exists to prevent infection with COVID-19, and at this time, few medications have shown benefit in decreasing morbidity and mortality. Until we achieve better outcomes – whether via vaccine, medication, or management – efforts to mitigate disease spread will remain a core strategy for fighting the virus.

Data suggest that COVID-19 will remain a factor to be managed in our lives and practices for a prolonged period of time. Scientific data should continue to guide disease treatment and optimization of the response to the pandemic.

Given current gaps in knowledge regarding the impact of COVID-19 on both patient response to fertility treatment and on early pregnancy, prospective research is critically needed as fertility centers re-initiate care. ASRM encourages fertility providers and their patients to participate in studies that will help our understanding of these issues. To this end, the ASRM affiliate, Society for Assisted Reproductive Technologies (SART), is adding COVID-19 related questions to the SART Clinic Outcome Reporting System (CORS) registry in an effort to better understand the impact of the disease on reproductive outcomes following the use of assisted reproductive technologies (ART).

Infertility patients, whose underlying medical conditions place them at increased risk of complications if infected with SARS-CoV-2, should be counseled regarding the risks and benefits of initiating fertility treatment during this pandemic. Such informed consent discussions should be individualized to each patient’s unique situation (e.g. see SART COVID toolkit). Considerations regarding whether or not to perform viral testing on patients, including the consequences of such testing, are discussed in more detail below.

Due to the stress involved in returning to reproductive care while the pandemic is still ongoing, as well as the potential for risks associated with reproduction during the COVID-19 pandemic, practices are advised to ensure that every patient is provided with a list of resources for support and counseling, including but not limited to, a referral list of mental health professionals who specialize in fertility/infertility counseling in reproductive medicine.

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